10070179CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10820 SANTA TERESA DR
CONTRACTOR-" ',PERMIT NO: 10070179
OWNER'S NAME:
,
PHONE NO:
LICENSED CONTRACTOR'S DECLARATION
r,
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic. it $ N-8
r� �'
Contractor IDuc���t.+� b�S*J4c*:e►. Date ?/27/to
MECH RESIDENTIAL COMMERCIAL
I hereby affirm that I am licensed under the provisions of Chapter. 9,
JOB DESCRIPTION: REMODEL KITCHEN &BREAKFST
(commencing with Section 7000) of Division 3 of the Business & Professions
AREA(248SQ);ADDITIONAL
LIGHTING INSTALLED
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self -insure for Worker's
Compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance, as provided for by
Section 3700 of the Labor Code, for the performance of the work for which this
Sq. Ft Floor Area:
Valuation: $95000
permit is issued. aj,)�f
APPLICANT CERTIFICATION
APN Number: 35613013.00
Occupancy Type:
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
PERMIT EXPIRES IF WORK IS NOT STARTED
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
with all non -point source regulations per the Cupertino Municipal Code, Section
180 DAYS FROM LAST CALLED INSPECTION.
9.18.
Signature Date
Issued by: Date:
❑ OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
RE -ROOFS:
the following two reasons:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
I, as owner of the property, or my employees with wages as their sole compensation,
installed without first obtaining an inspection, I agree to remove all new materials for
will do the work, and the structure is not intended or offered for sale (Sec.7044,
inspection.
Business & Professions Code)
I, as owner of the property, am exclusively contracting with licensed contractors to
Signature of Applicant: Date:
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
declarations:
1 have and will maintain a Certificate of Consent to self -insure for Worker's
Compensation, as provided for by Section 3700 of the Labor Code, for the
HAZARDOUS MATERIALS DISCLOSURE
performance of the work for which this permit is issued.
I have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain Worker's Compensation Insurance, as provided for by
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
Section 3700 of the Labor Code, for the performance of the work for which this
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should I store or handle hazardous material.
permit is issued.
Additionally, should I use equipment or devices which emit hazardous air
I certify that in the performance of the work for which this permit is issued, l shall
contaminants as defined by the Bay Area Air Quality Management District I will
not employ any person in any manner so as to become subject to the Worker's
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Compensation laws of California. If, after making this certificate of exemption, l
Health & Safety Code, Sections 25505, 25533, and 25534.
become subject to the Worker's Compensation provisions of the Labor Code, I must
forthwith comply with such provisions or this permit shall be deemed revoked.
Owner
Date: 7",27�
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
CONSTRUCTION LENDING AGENCY
correct. I agree to comply with all city and county ordinances and state laws relating
I hereby affirm that there is a construction lending agency for the performance of work's
to building construction, and hereby authorize representatives of this city to enter
for which this permit is issued (Sec. 3097, Civ C.)
upon the above mentioned property for inspection purposes. (We) agree to save
Lender's Name
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
Lender's Address
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.I8.
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Signature Date
Licensed Professional
CITY OF CUPERTINO
997a FEE ESTIMATOR - BUILDING DIVISION
OCCUPANCY TYPE:
ADDRESS:
FLR AREA
DATE:
REVIEWED BY:
lia
APN:
BP#:
'VALUATION: $95,000
PERMIT TYPE: Building Permit
$0.00
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY SFD or Duplex
USE:
hrs
OVER THE
COUNTER. 0 Yes (j) No
APPLICATION 1 R3SFDW
TYPE:
MECHANICAL ® Yes Q No
PLUMBING 0 Yes ) No
ELECTRICAL 0 Yes (j) No
as
Permit Fee:
00
Suppl. Insp. Feer Reg. 0
OT
3�
hrs
$0.00
OCCUPANCY TYPE:
TYPE OF
CONSTR.
FLR AREA
PC FEES
PC FEE ID
BP FEES
BP FEE ID
R-3 (Custom)
II-B,111-B,IV,V-B
0
$0.00
Suppl. PC Fee: E) Reg. 0 OT
$0.00
hrs
$0.00
PME Plan Check:
$0.002=
#
$380.00
Window / Sliding Glass Door
1WINREP Replacement
Permit Fee:
$0.00
Suppl. Insp. Feer Reg. 0
OT
0.0
hrs
$0.00
$42.00
Electrical
IBREMRECEP Recep/Switch/Outlets
PME Unit Fee:
$0.00
PME Permit Fee:
TOTALS:
0
$0.00
$0.00
Jt.
NOTE. These fees are based on the nreliminary information available and are nnly an estimate_ Contact the 1)ent fnr addn'1 infn
FEE ITEMS (Fee Resolution 09-051Ff .' 7/1.%09)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
248 s.f.
$570.00
Remodel, Kitchen (<=300 sf)
IREMRESKIT
Suppl. PC Fee: E) Reg. 0 OT
0.0
hrs
$0.00
PME Plan Check:
$0.002=
#
$380.00
Window / Sliding Glass Door
1WINREP Replacement
Permit Fee:
$0.00
Suppl. Insp. Feer Reg. 0
OT
0.0
hrs
$0.00
$42.00
Electrical
IBREMRECEP Recep/Switch/Outlets
PME Unit Fee:
$0.00
PME Permit Fee:
$42.00
#
$63.00
Electrical
IBREMFIXT Fixtures, Lighting
Acoustical Fee:
0 Yes (E) No
$0.00
E)
Work Without Permit? 0 Yes (D No
$0.00
Planningj
$0.00
Select a Non -Residential
Building or Structure
Q
0
Travel Documentation Fee: ITRA VDOC
$42.00
Strom Motion Fee:
IBSEISMICR
$9.50
Select an Administrative Item
Bid- Stds Commission Fee: IBCBSC
$4.00
SUBTOTALS:
$97.501$1,055.00)
TOTAL FEE:
$1,152.50
Revised: 7/22/2010